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EN BANC
DR. RUBI LI,
Petitioner,
G.R. No. 165279
Present:
CORONA, C.J.,
CARPIO,
CARPIO MORALES,
VELASCO, JR.,

2. - versus -
NACHURA,
LEONARDO-DE CASTRO,
BRION,
PERALTA,
BERSAMIN,
DEL CASTILLO,*
ABAD,
VILLARAMA, JR.,
PEREZ,
MENDOZA, and
SERENO, JJ.
SPOUSES REYNALDO and LINA
SOLIMAN, as parents/heirs of
deceased Angelica Soliman,
Respondents.
Promulgated:
June 7, 2011
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the
Decision dated June 15, 2004 as well as the
Resolution dated September 1, 2004 of the Court of Appeals (CA) in CA-
G.R. CV No. 58013 which modified the Decision dated September 5,
1997 of the Regional Trial Court of Legazpi City, Branch 8 in Civil Case
No. 8904.
The factual antecedents:
On July 7, 1993, respondents’ 11-year old daughter, Angelica
Soliman, underwent a biopsy of the mass located in her lower extremity

3. at the St. Luke’s Medical Center (SLMC). Results showed that Angelica
was suffering from osteosarcoma, osteoblastic type, a high-grade
(highly malignant) cancer of the bone which usually afflicts teenage
children. Following this diagnosis and as primary intervention,
Angelica’s right leg was amputated by Dr. Jaime Tamayo in order to
remove the tumor. As adjuvant treatment to eliminate any remaining
cancer cells, and hence minimize the chances of recurrence and
prevent the disease from spreading to other parts of the patient’s body
(metastasis), chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo
referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi
Li, a medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However,
she died on September 1, 1993, just eleven (11) days after the
(intravenous) administration of the first cycle of the chemotherapy
regimen. Because SLMC refused to release a death certificate without
full payment of their hospital bill, respondents brought the cadaver of
Angelica to the Philippine National Police (PNP) Crime Laboratory
at Camp Crame for post-mortem examination. The Medico-Legal
Report issued by said institution indicated the cause of death as
“Hypovolemic shock secondary to multiple organ hemorrhages and
Disseminated Intravascular Coagulation.”
On the other hand, the Certificate of Death issued by SLMC stated
the cause of death as follows:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy
On February 21, 1994, respondents filed a damage suit against
petitioner, Dr. Leo Marbella, Mr. Jose Ledesma, a certain Dr. Arriete
and SLMC. Respondents charged them with negligence and disregard of

4. Angelica’s safety, health and welfare by their careless administration of
the chemotherapy drugs, their failure to observe the essential
precautions in detecting early the symptoms of fatal blood platelet
decrease and stopping early on the chemotherapy, which bleeding led
to hypovolemic shock that caused Angelica’s untimely demise. Further,
it was specifically averred that petitioner assured the respondents that
Angelica would recover in view of 95% chance of healing with
chemotherapy (“Magiging normal na ang anak nyo basta ma-chemo.
95% ang healing”) and when asked regarding the side effects,
petitioner mentioned only slight vomiting, hair loss and weakness
(“Magsusuka ng kaunti. Malulugas ang buhok.
Manghihina”). Respondents thus claimed that they would not have
given their consent to chemotherapy had petitioner not falsely assured
them of its side effects.
In her answer,petitioner denied having been negligent in
administering the chemotherapy drugs to Angelica and asserted that
she had fully explained to respondents how the chemotherapy will
affect not only the cancer cells but also the patient’s normal body parts,
including the lowering of white and red blood cells and platelets. She
claimed that what happened to Angelica can be attributed to malignant
tumor cells possibly left behind after surgery. Few as they may be,
these have the capacity to compete for nutrients such that the body
becomes so weak structurally (cachexia) and functionally in the form of
lower resistance of the body to combat infection. Such infection
becomes uncontrollable and triggers a chain of events
(sepsis or septicemia) that may lead to bleeding in the form of
Disseminated Intravascular Coagulation (DIC), as what the autopsy
report showed in the case of Angelica.
Since the medical records of Angelica were not produced in court,
the trial and appellate courts had to rely on testimonial evidence,

5. principally the declarations of petitioner and respondents
themselves. The following chronology of events was gathered:
On July 23, 1993, petitioner saw the respondents at the hospital
after Angelica’s surgery and discussed with them Angelica’s
condition. Petitioner told respondents that Angelica should be given
two to three weeks to recover from the operation before starting
chemotherapy. Respondents were apprehensive due to financial
constraints as Reynaldo earns only from P70,000.00 to P150,000.00 a
year from his jewelry and watch repairing business. Petitioner,
however, assured them not to worry about her professional fee and
told them to just save up for the medicines to be used.
Petitioner claimed that she explained to respondents that even
when a tumor is removed, there are still small lesions undetectable to
the naked eye, and that adjuvant chemotherapy is needed to clean out
the small lesions in order to lessen the chance of the cancer to
recur. She did not give the respondents any assurance that
chemotherapy will cure Angelica’s cancer. During these consultations
with respondents, she explained the following side effects of
chemotherapy treatment to respondents: (1) falling hair; (2) nausea
and vomiting; (3) loss of appetite; (4) low count of white blood cells
[WBC], red blood cells [RBC] and platelets; (5) possible sterility due to
the effects on Angelica’s ovary; (6) damage to the heart and kidneys;
and (7) darkening of the skin especially when exposed to sunlight. She
actually talked with respondents four times, once at the hospital after
the surgery, twice at her clinic and the fourth time when Angelica’s
mother called her through long distance. This was disputed by
respondents who countered that petitioner gave them assurance that
there is 95% chance of healing for Angelica if she undergoes
chemotherapy and that the only side effects were nausea, vomiting and
hair loss. Those were the only side-effects of chemotherapy treatment
mentioned by petitioner.

6. On July 27, 1993, SLMC discharged Angelica, with instruction from
petitioner that she be readmitted after two or three weeks for the
chemotherapy.
On August 18, 1993, respondents brought Angelica to SLMC for
chemotherapy, bringing with them the results of the laboratory tests
requested by petitioner: Angelica’s chest x-ray, ultrasound of the liver,
creatinine and complete liver function tests. Petitioner proceeded with
the chemotherapy by first administering hydration fluids to Angelica.
The following day, August 19, petitioner began administering
three chemotherapy drugs – Cisplatin, Doxorubicin and Cosmegen –
intravenously. Petitioner was supposedly assisted by her trainees Dr.
Leo Marbella and Dr. Grace Arriete. In his testimony, Dr. Marbella
denied having any participation in administering the said chemotherapy
drugs.
On the second day of chemotherapy, August 20, respondents
noticed reddish discoloration on Angelica’s face. They asked petitioner
about it, but she merely quipped, “Wala yan. Epekto ng
gamot.” Petitioner recalled noticing the skin rashes on the nose and
cheek area of Angelica. At that moment, she entertained the possibility
that Angelica also had systemic lupus and consulted Dr. Victoria
Abesamis on the matter.
On the third day of chemotherapy, August 21, Angelica had
difficulty breathing and was thus provided with oxygen inhalation
apparatus. This time, the reddish discoloration on Angelica’s face had
extended to her neck, but petitioner dismissed it again as merely the
effect of medicines. Petitioner testified that she did not see any
discoloration on Angelica’s face, nor did she notice any difficulty in the
child’s breathing. She claimed that Angelica merely complained of
nausea and was given ice chips.

7. On August 22, 1993, at around ten o’clock in the morning, upon
seeing that their child could not anymore bear the pain, respondents
pleaded with petitioner to stop the chemotherapy. Petitioner
supposedly replied: “Dapat 15 Cosmegen pa iyan. Okay, let’s observe. If
pwede na, bigyan uli ng chemo.” At this point, respondents asked
petitioner’s permission to bring their child home. Later in the evening,
Angelica passed black stool and reddish urine. Petitioner countered
that there was no record of blackening of stools but only an episode of
loose bowel movement (LBM). Petitioner also testified that what
Angelica complained of was carpo-pedal spasm, not convulsion or
epileptic attack, as respondents call it (petitioner described it in the
vernacular as “naninigas ang kamay at paa”). She then requested for a
serum calcium determination and stopped the chemotherapy. When
Angelica was given calcium gluconate, the spasm and numbness
subsided.
The following day, August 23, petitioner yielded to respondents’
request to take Angelica home. But prior to discharging Angelica,
petitioner requested for a repeat serum calcium determination and
explained to respondents that the chemotherapy will be temporarily
stopped while she observes Angelica’s muscle twitching and serum
calcium level. Take-home medicines were also prescribed for Angelica,
with instructions to respondents that the serum calcium test will have
to be repeated after seven days. Petitioner told respondents that she
will see Angelica again after two weeks, but respondents can see her
anytime if any immediate problem arises.
However, Angelica remained in confinement because while still in
the premises of SLMC, her “convulsions” returned and she also had
LBM. Angelica was given oxygen and administration of calcium
continued.

8. The next day, August 24, respondents claimed that Angelica still
suffered from convulsions. They also noticed that she had a fever and
had difficulty breathing. Petitioner insisted it was carpo-pedal spasm,
not convulsions. She verified that at around 4:50 that afternoon,
Angelica developed difficulty in breathing and had fever. She then
requested for an electrocardiogram analysis, and infused calcium
gluconate on the patient at a “stat dose.” She further ordered that
Angelica be given Bactrim, a synthetic antibacterial combination drug, to
combat any infection on the child’s body.
By August 26, Angelica was bleeding through the mouth.
Respondents also saw blood on her anus and urine. When Lina asked
petitioner what was happening to her daughter, petitioner replied,
“Bagsak ang platelets ng anak mo.” Four units of platelet concentrates
were then transfused to Angelica. Petitioner prescribed Solucortef.
Considering that Angelica’s fever was high and her white blood cell
count was low, petitioner prescribed Leucomax. About four to eight
bags of blood, consisting of packed red blood cells, fresh whole blood,
or platelet concentrate, were transfused to Angelica. For two days
(August 27 to 28), Angelica continued bleeding, but petitioner claimed
it was lesser in amount and in frequency. Petitioner also denied that
there were gadgets attached to Angelica at that time.
On August 29, Angelica developed ulcers in her mouth, which
petitioner said were blood clots that should not be
removed. Respondents claimed that Angelica passed about half a liter
of blood through her anus at around seven o’clock that evening, which
petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as
endotracheal and nasogastric tubes were inserted into her weakened
body. An aspiration of the nasogastric tube inserted to Angelica also
revealed a bloody content. Angelica was given more platelet

9. concentrate and fresh whole blood, which petitioner claimed improved
her condition. Petitioner told Angelica not to remove the endotracheal
tube because this may induce further bleeding. She was also
transferred to the intensive care unit to avoid infection.
The next day, respondents claimed that Angelica became
hysterical, vomited blood and her body turned black. Part of Angelica’s
skin was also noted to be shredding by just rubbing cotton on
it. Angelica was so restless she removed those gadgets attached to
her, saying “Ayaw ko na”; there were tears in her eyes and she kept
turning her head. Observing her daughter to be at the point of death,
Lina asked for a doctor but the latter could not answer her anymore. At
this time, the attending physician was Dr. Marbella who was shaking his
head saying that Angelica’s platelets were down and respondents
should pray for their daughter. Reynaldo claimed that he was
introduced to a pediatrician who took over his daughter’s case, Dr.
Abesamis who also told him to pray for his daughter. Angelica
continued to have difficulty in her breathing and blood was being
suctioned from her stomach. A nurse was posted inside Angelica’s
room to assist her breathing and at one point they had to revive
Angelica by pumping her chest. Thereafter, Reynaldo claimed that
Angelica already experienced difficulty in urinating and her bowel
consisted of blood-like fluid. Angelica requested for an electric fan as
she was in pain. Hospital staff attempted to take blood samples from
Angelica but were unsuccessful because they could not even locate her
vein. Angelica asked for a fruit but when it was given to her, she only
smelled it. At this time, Reynaldo claimed he could not find either
petitioner or Dr. Marbella. That night, Angelica became hysterical and
started removing those gadgets attached to her. At three o’clock in
the morning of September 1, a priest came and they prayed before
Angelica expired. Petitioner finally came back and supposedly told
respondents that there was “malfunction” or bogged-down machine.

10. By petitioner’s own account, Angelica was merely irritable that
day (August 31). Petitioner noted though that Angelica’s skin was
indeed sloughing off. She stressed that at 9:30 in the evening, Angelica
pulled out her endotracheal tube. On September 1, exactly two weeks
after being admitted at SLMC for chemotherapy, Angelica died. The
cause of death, according to petitioner, was septicemia, or
overwhelming infection, which caused Angelica’s other organs to
fail. Petitioner attributed this to the patient’s poor defense mechanism
brought about by the cancer itself.
While he was seeking the release of Angelica’s cadaver from
SLMC, Reynaldo claimed that petitioner acted arrogantly and called him
names. He was asked to sign a promissory note as he did not have cash
to pay the hospital bill.
Respondents also presented as witnesses Dr. Jesusa Nieves-
Vergara, Medico-Legal Officer of the PNP-Crime Laboratory who
conducted the autopsy on Angelica’s cadaver, and Dr. Melinda Vergara
Balmaceda who is a Medical Specialist employed at the Department of
Health (DOH) Operations and Management Services.
Testifying on the findings stated in her medico-legal report, Dr.
Vergara noted the following: (1) there were fluids recovered from the
abdominal cavity, which is not normal, and was due to hemorrhagic
shock secondary to bleeding; (2) there was hemorrhage at the left side
of the heart; (3) bleeding at the upper portion of and areas adjacent to,
the esophagus; (4) lungs were heavy with bleeding at the back and
lower portion, due to accumulation of fluids; (4) yellowish discoloration
of the liver; (5) kidneys showed appearance of facial shock on account
of hemorrhages; and (6) reddishness on external surface of the spleen.
All these were the end result of “hypovolemic shock secondary to
multiple organ hemorrhages and disseminated intravascular
coagulation.” Dr. Vergara opined that this can be attributed to the

11. chemical agents in the drugs given to the victim, which caused platelet
reduction resulting to bleeding sufficient to cause the victim’s
death. The time lapse for the production of DIC in the case of Angelica
(from the time of diagnosis of sarcoma) was too short, considering the
survival rate of about 3 years. The witness conceded that the victim
will also die of osteosarcoma even with amputation or chemotherapy,
but in this case Angelica’s death was not caused by osteosarcoma. Dr.
Vergara admitted that she is not a pathologist but her statements were
based on the opinion of an oncologist whom she had interviewed. This
oncologist supposedly said that if the victim already had DIC prior to
the chemotherapy, the hospital staff could have detected it.
On her part, Dr. Balmaceda declared that it is the physician’s duty
to inform and explain to the patient or his relatives every known side
effect of the procedure or therapeutic agents to be administered,
before securing the consent of the patient or his relatives to such
procedure or therapy. The physician thus bases his assurance to the
patient on his personal assessment of the patient’s condition and his
knowledge of the general effects of the agents or procedure that will be
allowed on the patient. Dr. Balmaceda stressed that the patient or
relatives must be informed of all known side effects based on studies
and observations, even if such will aggravate the patient’s condition.
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on
Angelica’s lower extremity, testified for the defendants. He explained
that in case of malignant tumors, there is no guarantee that the
ablation or removal of the amputated part will completely cure the
cancer. Thus, surgery is not enough. The mortality rate of
osteosarcoma at the time of modern chemotherapy and early diagnosis
still remains at 80% to 90%. Usually, deaths occur from metastasis, or
spread of the cancer to other vital organs like the liver, causing
systemic complications. The modes of therapy available are the
removal of the primary source of the cancerous growth and then the

12. residual cancer cells or metastasis should be treated with
chemotherapy. Dr. Tamayo further explained that patients with
osteosarcoma have poor defense mechanism due to the cancer cells in
the blood stream. In the case of Angelica, he had previously explained
to her parents that after the surgical procedure, chemotherapy is
imperative so that metastasis of these cancer cells will hopefully be
addressed. He referred the patient to petitioner because he felt that
petitioner is a competent oncologist. Considering that this type of
cancer is very aggressive and will metastasize early, it will cause the
demise of the patient should there be no early intervention (in this
case, the patient developed sepsis which caused her death). Cancer
cells in the blood cannot be seen by the naked eye nor detected
through bone scan. On cross-examination, Dr. Tamayo stated that of
the more than 50 child patients who had osteogenic sarcoma he had
handled, he thought that probably all of them died within six months
from amputation because he did not see them anymore after follow-
up; it is either they died or had seen another doctor.
In dismissing the complaint, the trial court held that petitioner
was not liable for damages as she observed the best known procedures
and employed her highest skill and knowledge in the administration of
chemotherapy drugs on Angelica but despite all efforts said patient
died. It cited the testimony of Dr. Tamayo who testified that he
considered petitioner one of the most proficient in the treatment of
cancer and that the patient in this case was afflicted with a very
aggressive type of cancer necessitating chemotherapy as adjuvant
treatment. Using the standard of negligence laid down in Picart v.
Smith, the trial court declared that petitioner has taken the necessary
precaution against the adverse effect of chemotherapy on the patient,
adding that a wrong decision is not by itself negligence. Respondents
were ordered to pay their unpaid hospital bill in the amount
ofP139,064.43.

13. Respondents appealed to the CA which, while concurring with
the trial court’s finding that there was no negligence committed by the
petitioner in the administration of chemotherapy treatment to
Angelica, found that petitioner as her attending physician failed to fully
explain to the respondents all the known side effects of
chemotherapy. The appellate court stressed that since the
respondents have been told of only three side effects of chemotherapy,
they readily consented thereto. Had petitioner made known to
respondents those other side effects which gravely affected their child -
- such as carpo-pedal spasm, sepsis, decrease in the blood platelet
count, bleeding, infections and eventual death -- respondents could
have decided differently or adopted a different course of action which
could have delayed or prevented the early death of their child.
The CA thus declared:
Plaintiffs-appellants’ child was suffering from a
malignant disease. The attending physician recommended
that she undergo chemotherapy treatment after surgery in
order to increase her chances of survival. Appellants
consented to the chemotherapy treatment because they
believed in Dr. Rubi Li’s representation that the deceased
would have a strong chance of survival after chemotherapy
and also because of the representation of appellee Dr. Rubi
Li that there were only three possible side-effects of the
treatment. However, all sorts of painful side-effects resulted
from the treatment including the premature death of
Angelica. The appellants were clearly and totally unaware
of these other side-effects which manifested only during
the chemotherapy treatment. This was shown by the fact
that every time a problem would take place regarding
Angelica’s condition (like an unexpected side-effect
manifesting itself), they would immediately seek

14. explanation from Dr. Rubi Li. Surely, those unexpected
side-effects culminating in the loss of a love[d] one caused
the appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee
Dr. Rubi Li negligent which would entitle plaintiffs-appellants
to their claim for damages.
x x x x
WHEREFORE, the instant appeal is hereby
GRANTED. Accordingly, the assailed decision is hereby
modified to the extent that defendant-appellee Dr. Rubi Li is
ordered to pay the plaintiffs-appellants the following
amounts:
1. Actual damages of P139,064.43, plus P9,828.00
for funeral expenses;
2. Moral damages of P200,000.00;
3. Exemplary damages of P50,000.00;
4. Attorney’s fee of P30,000.00.
SO ORDERED.
Petitioner filed a motion for partial reconsideration which the
appellate court denied.
Hence, this petition.
Petitioner assails the CA in finding her guilty of negligence in not
explaining to the respondents all the possible side effects of the
chemotherapy on their child, and in holding her liable for actual, moral
and exemplary damages and attorney’s fees. Petitioner emphasized

15. that she was not negligent in the pre-chemotherapy procedures and in
the administration of chemotherapy treatment to Angelica.
On her supposed non-disclosure of all possible side effects of
chemotherapy, including death, petitioner argues that it was foolhardy
to imagine her to be all-knowing/omnipotent. While the theoretical
side effects of chemotherapy were explained by her to the
respondents, as these should be known to a competent
doctor, petitioner cannot possibly predict how a particular patient’s
genetic make-up, state of mind, general health and body constitution
would respond to the treatment. These are obviously dependent on
too many known, unknown and immeasurable variables, thus requiring
that Angelica be, as she was, constantly and closely monitored during
the treatment. Petitioner asserts that she did everything within her
professional competence to attend to the medical needs of Angelica.
Citing numerous trainings, distinctions and achievements in her
field and her current position as co-director for clinical affairs of the
Medical Oncology, Department of Medicine of SLMC, petitioner
contends that in the absence of any clear showing or proof, she cannot
be charged with negligence in not informing the respondents all the
side effects of chemotherapy or in the pre-treatment procedures done
on Angelica.
As to the cause of death, petitioner insists that Angelica did not
die of platelet depletion but of sepsis which is a complication of the
cancer itself. Sepsis itself leads to bleeding and death. She explains
that the response rate to chemotherapy of patients with osteosarcoma
is high, so much so that survival rate is favorable to the
patient. Petitioner then points to some probable consequences if
Angelica had not undergone chemotherapy. Thus, without
chemotherapy, other medicines and supportive treatment, the patient
might have died the next day because of massive infection, or the

16. cancer cells might have spread to the brain and brought the patient
into a coma, or into the lungs that the patient could have been hooked
to a respirator, or into her kidneys that she would have to undergo
dialysis. Indeed, respondents could have spent as much because of
these complications. The patient would have been deprived of the
chance to survive the ailment, of any hope for life and her “quality of
life” surely compromised. Since she had not been shown to be at fault,
petitioner maintains that the CA erred in holding her liable for the
damages suffered by the respondents.
The issue to be resolved is whether the petitioner can be held
liable for failure to fully disclose serious side effects to the parents of
the child patient who died while undergoing chemotherapy, despite the
absence of finding that petitioner was negligent in administering the
said treatment.
The petition is meritorious.
The type of lawsuit which has been called medical malpractice or,
more appropriately, medical negligence, is that type of claim which a
victim has available to him or her to redress a wrong committed by a
medical professional which has caused bodily harm. In order to
successfully pursue such a claim, a patient must prove that a health
care provider, in most cases a physician, either failed to do something
which a reasonably prudent health care provider would have done, or
that he or she did something that a reasonably prudent provider would
not have done; and that that failure or action caused injury to the
patient.
This Court has recognized that medical negligence cases are best
proved by opinions of expert witnesses belonging in the same general
neighborhood and in the same general line of practice as defendant
physician or surgeon. The deference of courts to the expert opinion of

17. qualified physicians stems from the former’s realization that the latter
possess unusual technical skills which laymen in most instances are
incapable of intelligently evaluating, hence the indispensability of
expert testimonies.
In this case, both the trial and appellate courts concurred in
finding that the alleged negligence of petitioner in the administration of
chemotherapy drugs to respondents’ child was not proven considering
that Drs. Vergara and Balmaceda, not being oncologists or cancer
specialists, were not qualified to give expert opinion as to whether
petitioner’s lack of skill, knowledge and professional competence in
failing to observe the standard of care in her line of practice was the
proximate cause of the patient’s death. Furthermore, respondents’
case was not at all helped by the non-production of medical records by
the hospital (only the biopsy result and medical bills were submitted to
the court). Nevertheless, the CA found petitioner liable for her failure
to inform the respondents on all possible side effects of chemotherapy
before securing their consent to the said treatment.
The doctrine of informed consent within the context of physician-
patient relationships goes far back into English common law. As early
as 1767, doctors were charged with the tort of “battery” (i.e., an
unauthorized physical contact with a patient) if they had not gained the
consent of their patients prior to performing a surgery or procedure. In
theUnited States, the seminal case was Schoendorff v. Society of New
York Hospital which involved unwanted treatment performed by a
doctor. Justice Benjamin Cardozo’s oft-quoted opinion upheld the basic
right of a patient to give consent to any medical procedure or
treatment: “Every human being of adult years and sound mind has a
right to determine what shall be done with his own body; and a
surgeon who performs an operation without his patient’s consent,
commits an assault, for which he is liable in damages.” From a purely
ethical norm, informed consent evolved into a general principle of law

18. that a physician has a duty to disclose what a reasonably prudent
physician in the medical community in the exercise of reasonable care
would disclose to his patient as to whatever grave risks of injury might
be incurred from a proposed course of treatment, so that a patient,
exercising ordinary care for his own welfare, and faced with a choice of
undergoing the proposed treatment, or alternative treatment, or none
at all, may intelligently exercise his judgment by reasonably balancing
the probable risks against the probable benefits.
Subsequently, in Canterbury v. Spence the court observed that the
duty to disclose should not be limited to medical usage as to arrogate
the decision on revelation to the physician alone. Thus, respect for the
patient’s right of self-determination on particular therapy demands a
standard set by law for physicians rather than one which physicians
may or may not impose upon themselves. The scope of disclosure is
premised on the fact that patients ordinarily are persons unlearned in
the medical sciences. Proficiency in diagnosis and therapy is not the full
measure of a physician’s responsibility. It is also his duty to warn of the
dangers lurking in the proposed treatment and to impart information
which the patient has every right to expect. Indeed, the patient’s
reliance upon the physician is a trust of the kind which traditionally has
exacted obligations beyond those associated with armslength
transactions. The physician is not expected to give the patient a short
medical education, the disclosure rule only requires of him a
reasonable explanation, which means generally informing the patient in
nontechnical terms as to what is at stake; the therapy alternatives open
to him, the goals expectably to be achieved, and the risks that may
ensue from particular treatment or no treatment. As to the issue of
demonstrating what risks are considered material necessitating
disclosure, it was held that experts are unnecessary to a showing of the
materiality of a risk to a patient’s decision on treatment, or to the
reasonably, expectable effect of risk disclosure on the decision. Such
unrevealed risk that should have been made known must further

19. materialize, for otherwise the omission, however unpardonable, is
without legal consequence. And, as in malpractice actions generally,
there must be a causal relationship between the physician’s failure to
divulge and damage to the patient.
Reiterating the foregoing considerations, Cobbs v. Grant deemed
it as integral part of physician’s overall obligation to patient, the duty of
reasonable disclosure of available choices with respect to proposed
therapy and of dangers inherently and potentially involved in
each. However, the physician is not obliged to discuss relatively minor
risks inherent in common procedures when it is common knowledge
that such risks inherent in procedure of very low incidence. Cited as
exceptions to the rule that the patient should not be denied the
opportunity to weigh the risks of surgery or treatment are emergency
cases where it is evident he cannot evaluate data, and where the
patient is a child or incompetent. The court thus concluded that the
patient’s right of self-decision can only be effectively exercised if the
patient possesses adequate information to enable him in making an
intelligent choice. The scope of the physician’s communications to the
patient, then must be measured by the patient’s need, and that need is
whatever information is material to the decision. The test therefore for
determining whether a potential peril must be divulged is its materiality
to the patient’s decision.
Cobbs v. Grant further reiterated the pronouncement
in Canterbury v. Spence that for liability of the physician for failure to
inform patient, there must be causal relationship between physician’s
failure to inform and the injury to patient and such connection arises
only if it is established that, had revelation been made, consent to
treatment would not have been given.
There are four essential elements a plaintiff must prove in a
malpractice action based upon the doctrine of informed consent: “(1)

20. the physician had a duty to disclose material risks; (2) he failed to
disclose or inadequately disclosed those risks; (3) as a direct and
proximate result of the failure to disclose, the patient consented to
treatment she otherwise would not have consented to; and (4) plaintiff
was injured by the proposed treatment.” The gravamen in an informed
consent case requires the plaintiff to “point to significant undisclosed
information relating to the treatment which would have altered her
decision to undergo it.
Examining the evidence on record, we hold that there was
adequate disclosure of material risks inherent in the chemotherapy
procedure performed with the consent of Angelica’s
parents. Respondents could not have been unaware in the course of
initial treatment and amputation of Angelica’s lower extremity, that her
immune system was already weak on account of the malignant tumor
in her knee. When petitioner informed the respondents beforehand of
the side effects of chemotherapy which includes lowered counts of
white and red blood cells, decrease in blood platelets, possible kidney
or heart damage and skin darkening, there is reasonable expectation on
the part of the doctor that the respondents understood very well that
the severity of these side effects will not be the same for all patients
undergoing the procedure. In other words, by the nature of the disease
itself, each patient’s reaction to the chemical agents even with pre-
treatment laboratory tests cannot be precisely determined by the
physician. That death can possibly result from complications of the
treatment or the underlying cancer itself, immediately or sometime
after the administration of chemotherapy drugs, is a risk that cannot be
ruled out, as with most other major medical procedures, but such
conclusion can be reasonably drawn from the general side effects of
chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents
to have considered the variables in the recommended treatment for

21. their daughter afflicted with a life-threatening illness. On the other
hand, it is difficult to give credence to respondents’ claim that
petitioner told them of 95% chance of recovery for their daughter, as it
was unlikely for doctors like petitioner who were dealing with grave
conditions such as cancer to have falsely assured patients of
chemotherapy’s success rate. Besides, informed consent laws in other
countries generally require only a reasonable explanation of potential
harms, so specific disclosures such as statistical data, may not be legally
necessary.
The element of ethical duty to disclose material risks in the
proposed medical treatment cannot thus be reduced to one simplistic
formula applicable in all instances. Further, in a medical malpractice
action based on lack of informed consent, “the plaintiff must prove
both the duty and the breach of that duty through expert
testimony. Such expert testimony must show the customary standard
of care of physicians in the same practice as that of the defendant
doctor.
In this case, the testimony of Dr. Balmaceda who is not an
oncologist but a Medical Specialist of the DOH’s Operational and
Management Services charged with receiving complaints against
hospitals, does not qualify as expert testimony to establish the
standard of care in obtaining consent for chemotherapy treatment. In
the absence of expert testimony in this regard, the Court feels hesitant
in defining the scope of mandatory disclosure in cases of malpractice
based on lack of informed consent, much less set a standard of
disclosure that, even in foreign jurisdictions, has been noted to be an
evolving one.
As society has grappled with the juxtaposition between
personal autonomy and the medical profession's intrinsic
impetus to cure, the law defining “adequate” disclosure has

22. undergone a dynamic evolution. A standard once guided
solely by the ruminations of physicians is now dependent on
what a reasonable person in the patient’s position regards
as significant. This change in perspective is especially
important as medical breakthroughs move practitioners to
the cutting edge of technology, ever encountering new and
heretofore unimagined treatments for currently incurable
diseases or ailments. An adaptable standard is needed to
account for this constant progression. Reasonableness
analyses permeate our legal system for the very reason that
they are determined by social norms, expanding and
contracting with the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we
now realize that the legal standard of disclosure is not
subject to construction as a categorical
imperative. Whatever formulae or processes we adopt are
only useful as a foundational starting point; the particular
quality or quantity of disclosure will remain inextricably
bound by the facts of each case. Nevertheless, juries that
ultimately determine whether a physician properly informed
a patient are inevitably guided by what they perceive as the
common expectation of the medical consumer—“a
reasonable person in the patient’s position when deciding to
accept or reject a recommended medical procedure.”
WHEREFORE, the petition for review on certiorari
is GRANTED. The Decision dated June 15, 2004 and the Resolution
dated September 1, 2004 of the Court of Appeals in CA-G.R. CV No.
58013 are SET ASIDE.

23. The Decision dated September 5, 1997 of
the Regional Trial Court of Legazpi City, Branch 8, in Civil Case No. 8904
is REINSTATED and UPHELD.
No costs.
SO ORDERED.